International Journal of Mental Health and Addiction (2021) 19:1162–1189
https://doi.org/10.1007/s11469-019-00217-8
ORIGINAL ARTICLE
Anabolic-Androgenic Steroid Use in the Eastern
Mediterranean Region: a Scoping Review of Extant
Empirical Literature
Evelyn Hearne 1 & Mayyada Wazaify 2 & Marie Claire Van Hout 1 & Amanda Atkinson 1 &
Jim McVeigh 3
Published online: 15 January 2020
# The Author(s) 2020
Abstract
The use of image- and performance-enhancing drugs particularly anabolic-androgenic
steroids (AAS) is not a new phenomenon. AAS use is not limited to athletes, with
mainstream populations using these drugs for aesthetic purposes. Prevalence has been
predominantly in Western countries, with some recent studies indicating a rise in popularity in the Eastern Mediterranean region. A scoping review of extant empirical literature
from the Eastern Mediterranean region described and mapped what is known about the
extent of AAS in the region. Four themes emerged from the review: (1) profile of AAS
users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge
and understanding of the AAS concept and related adverse effects. The review highlights
a relatively new phenomenon of AAS use in the Eastern Mediterranean. The review
underscores the need to carry out further research, particularly qualitative and quantitative
studies with both genders, and cognisant of the complexities of culture and religiosity.
Keywords Anabolic steroids . Eastern Mediterranean . Gym users . Image- and performanceenhancing drugs
The use of image- and performance-enhancing drugs (IPEDs) particularly anabolic-androgenic
steroids (AAS) is not a new phenomenon (Dimeo 2007; Hoberman 2001; Yesalis 2001; Zahnow
et al. 2018). Globally, rising numbers of individuals who want to have an improved physique and
increased well-being revert to the use of IPEDs (Evans-Brown et al. 2012), and particularly amongst
* Evelyn Hearne
E.Hearne@ljmu.ac.uk
1
Public Health Institute (PHI), Faculty of Health, Liverpool John Moores University, Liverpool, UK
2
Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, University of Jordan,
Amman, Jordan
3
Department of Sociology, Manchester Metropolitan University, Manchester, UK
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
1163
gym populations (Kimergard and McVeigh 2014). Anabolic-androgenic steroids are a common
IPED and are synthetic derivatives of testosterone, the male sex hormone (Evans 2004; Kicman
2008; McVeigh and Begley 2017; Pope et al. 2014a, 2014b). These substances emulate biological
characteristics of these male hormones thus reproducing the effects on the body, resulting in the
growth of male sexual characteristics and skeletal muscle (Pope and Kanayama 2012; Sagoe et al.
2014a, 2014b; Sobhanian et al. 2013). They are used medically to treat a number of conditions
including protein-calorie malnutrition associated with weight loss, HIV wasting syndrome
(Mulligan and Schambelan 2002), and primary and secondary hypogonadism (Behre et al. 1999;
Nieschlag 2006; Sarosdy 2007; Taylor 2002). The use of AAS for performance-enhancing purposes
amongst athletes has been reported since the 1950s (Hakansson et al. 2012; Hoberman 1992;
Kanayama et al. 2008; Kanayama and Pope 2018; Mottram 2018; Yesalis 2000; Zahnow et al.
2018). Currently, the majority of users of AAS are not competing athletes, with patterns of use
primarily for aesthetic purposes (Begley et al. 2017; Kimergard and McVeigh 2014; Parkinson and
Evans 2006; Pope et al. 2012; Pope et al. 2014a, 2014b; Santos and Coomber 2017). These users
focus primarily on their appearance, body weight, muscle build, and leanness as opposed to their
athletic performance (Hakansson et al. 2012; Parkinson and Evans 2006; Petersson et al. 2010). In
1999, the World Anti-Doping Agency (WADA) was established to monitor drug use (doping) in
sport. The anti-doping code was adopted in 2003 and acts as a framework for sports organisations to
enable them to implement rules, regulations, and policies within sport. WADA and the CODE
protect athlete’s fundamental rights to participate in sport that is doping-free, promotes equality and
fairness for athletes worldwide, and ensures effective detection, deterrence, and prevention programs
are harmonised worldwide (WADA 2019).
There are numerous adverse health consequences that can result from the use of AAS. Of
concern is the long-term morbidity and mortality due to cardiovascular (Baggish et al. 2017)
hepatic (Creagh et al. 1988; Schumacher et al. 1999) and cognitive effects (Bjornebekk et al.
2017; Westlye et al. 2017) of AAS use. Other health consequences include those affecting
other organ systems such as gynaecomastia, acne, hair loss (Pope et al. 2014a, 2014b), and
impaired sexual function (Kanayama and Pope Jr. 2012). Psychological effects of AAS use
include mood disturbances (Kanayama and Pope Jr. 2012) and dependence (Pope et al. 2014a,
2014b). Some of these adverse effects are acute but subside once the use of AAS has ceased.
Chronic conditions can result from the long-term use of these substances (Pope et al. 2014a,
2014b). Lindqvist et al. (2013) reported an association between the past use of AAS and longterm poorer mental health outcomes. Negative psychological states have also been reported
such as depression, increased aggression, and anxiety (Pope et al. 2005) and with the severity
of these possibly dependent on AAS dosage (Kimergard and McVeigh 2014).
Traditionally AAS for image and performance enhancement have been taken in ‘cycles’.
These regimens involve periods of use of the substances that last 6 to 12 weeks, sometimes
more (Yesalis 2000). Research has indicated an increased cycle (the period that drugs are used)
length whereby users utilise a ‘blast and cruise’ method. This phenomenon is when the user
replaces the ‘off-cycle’ with a period of lower dosage. This has implications for the recovery of
testosterone production and health outcomes (Chandler and McVeigh 2014). Users of AAS
regularly consume a range of substances simultaneously known as ‘stacking’ (Sagoe et al.
2015; Yesalis 2000). The reasons for stacking are an endeavour to achieve synergistic effects
which allows the user to stimulate more receptor sites, thus creating greater anabolic effects
(Duchaine 1989; Nilsson 2001; Yesalis 2000). Additionally, those who inject AAS, which is
the primary route of administration (Bates et al. 2017), are at further risk of harms such as
injecting site wounds, injecting errors such as the incident reported in Jordan in 2002, which
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
was associated with the death of a 22 year old (Boulad 2003), bacterial and fungal infections in
the event of sharing injecting equipment, and the transmission of blood borne viruses (ACMD
2010; Bates et al. 2017; Bates and McVeigh 2016). Appropriate harm reduction interventions
targeting AAS users are crucial to preventing these adverse outcomes (Glass et al. 2019).
In terms of prevalence of this phenomenon, Sagoe and Pallesen (2018) have suggested that
AAS use is generally recorded as more prevalent in Western countries, Brazil and the Middle
East, and less widespread in Asia and Africa. Studies carried out in Eastern Mediterranean
countries indicate that the use of AAS, whilst low, is on the rise and therefore a growing
concern. Hence, we conducted a scoping review of extant empirical literature to describe and
map what is known about the relatively new phenomenon of AAS use in the Eastern
Mediterranean.
Methods
Scoping reviews are increasingly utilised as independent research methodologies to
address broader research questions in comparison to systematic reviews (Arksey and
O’Malley 2005; Khalil et al. 2016; Levac et al. 2010; Peters et al. 2015). They are
usually conducted to identify gaps in knowledge, examine the extent (i.e. size), range
(i.e. variety), and nature (i.e. characteristics) of the evidence on a certain topic or
question (in this case, AAS use in the Eastern Mediterranean), summarise findings from
a heterogeneous body of knowledge, or set agendas for future research and policy
directives (Arksey and O’Malley 2005; Brandt et al. 2014; Daudt et al. 2013; Levac
et al. 2010; Tricco et al. 2016). Scoping reviews are defined by Tricco et al. (2016) as ‘a
type of knowledge synthesis, follow a systematic approach to map evidence on a topic
and identify main concepts, theories, sources, and knowledge gaps.’
We adhered to Arksey and O’Malley’s (2005) five stage iterative process scoping review
methodology. These stages included the following: (1) identifying the essential research
question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5)
collecting, summarising, and reporting the results. The process was underpinned by the
research question (What do we know about AAS use in the Eastern Mediterranean region?)
and reviewed all available published empirical literature in the English language on this topic.
There was no restriction on date. To enable the broadest picture of current knowledge and
perceptions relating to this issue, we included policy documents and international and national
reports, online reports, conference proceedings, commentary pieces, and editorials, in addition
to articles in scholarly peer reviewed journals. The search was implemented in April 2019. We
used the following databases: Web of Science; Cochrane Library; MEDLINE; PsycINFO;
SPORTDiscus; Social Science Citation Index; Conf Proceedings Citation index; PubMED;
Science Direct; and Researchgate. A thorough list of key search terms used in AAS research
articles known to the research team (who had public health, addiction, and clinical specialisms)
informed the search strategy (see Table 1).
Eligibility criteria focused on use of AAS in Eastern Mediterranean Countries, i.e. Afghanistan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon,
Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan,
Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen (WHO, 2019). Inclusion
and exclusion criteria were discussed and agreed with all members of the research team.
Clinical case reports, case series, and laboratory analysis only studies were excluded. The
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Table 1 Search terms
Key word
Alternative
Anabolic Androgenic
Steroids
Muscle
anabolic steroids OR anabolic-androgenic OR anabolic hormones OR performance
enhancing OR doping OR image enhancing OR IPED OR PIED OR PED OR PEA
sport OR athletes OR muscle OR gym OR fitness OR bodybuild OR weight lift OR
physique OR gymnasium OR commercial club
Middle East OR Eastern Mediterranean OR Arab OR Afghanistan OR Bahrain OR
Djibouti OR Egypt OR Iran OR Iraq OR Jordan OR Kuwait OR Lebanon OR Libya
OR Morocco OR Oman OR Pakistan OR Qatar OR Saudi Arabia OR Somalia OR
Sudan OR Syria OR Tunisia OR United Arab Emirates OR Yemen
Middle Eastern
Countries
initial search identified 477 articles; and following initial screening, 355 were removed for lack
of relevance, with the remaining 122 screened for inclusion in the study. Finally, duplicates
(n = 51) and further records excluded for lack of relevance were removed (n = 32), leaving 39
records in total (see Fig. 1).
The 39 records were charted and thematically analysed, as per Arksey and O’Malley
(2005). A table was created using Microsoft Word to chart relevant data (year of
publication, author, location, method and aim, key findings, and conclusion) and to
analyse the extracted data thematically to identify commonalities, emergent issues, and
gaps in the literature. A trial charting exercise of several records was conducted by the
lead author as recommended by Daudt et al. (2013). This was followed by a team
consultation to ensure consistency with the research question and the scoping review
aim, and to identify prior categories to support further data extraction and charting. The
textual dataset was re-read numerous times by author one to gain familiarity with the
data and identify and code emerging themes. The charted data was analysed and
systematised by thematic manual coding, which organised the data and subsequently
structured into themes through patterns identified in associated categories (Crossley
Fig. 1 Flow chart of the search strategy used
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
2007). Following data analysis, two papers were omitted (Boos et al. 2011; Cassler et al.
2013) as their results showed that n = 0 AAS users were found in their studies, leaving a
final number of 37 included studies in the review (see Fig. 2). Four themes emerged from
the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS
regimes of use; and (4) knowledge and understanding of the AAS concept and related
adverse effects.
Results
We included published empirical records on AAS from searches in the twenty-one countries
located in the Eastern Mediterranean region. The types of records included were survey studies
in Saudi Arabia (Al Bishi and Afify 2017; Al Ghobain et al. 2016; Al Nozha and Elshatarat
2017; Alharbi et al. 2019; Althobiti et al. 2018; Bahri et al. 2017; Jabari et al. 2016), United
Arab Emirates (Al-Falasi et al. 2008), Kuwait (Allafi et al. 2019; Alsaeed and Alabkal 2015;
Khullar et al. 2016), Iran (Allahverdipour et al. 2012; Angoorani and Halabchi 2015; Asr et al.
2018; Bordbar et al. 2014; Fijan et al. 2018; Haerinejad et al. 2016; Jalilian et al. 2011;
Kargarfard et al. 2015; Mohammad 2014; Nakhaee et al. 2013; Razavi et al. 2014; Rezaei
2017; Saeidinejat et al. 2017; Sepehri et al. 2009; Sobhanian et al. 2013), Iraq (Boos et al.
2010; Habeeb et al. 2012), Lebanon (Hitti et al. 2014; Melki et al. 2015), Jordan (Tahtamouni
et al. 2008; Wazaify et al. 2014), Pakistan (Hussain et al. 2018; Uddin et al. 2019; Zafar et al.
2018), and Sudan (Khidir and Mahmoud 2018); and conference proceedings from Bahrain
(Alsamani et al. 2017) (see Table 2).
Fig. 2 Updated flow chart following data analysis
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2016
2006
2015
2016
Not stated
2008–2009 Iran
Al Bishi and
Afify 2017
Al-Falasi et al.
2008
Al Ghobain
et al. 2016
Alharbi et al.
2019
Allafi et al..,
2019
Allahverdipour
et al. 2012
Kuwait
Saudi Arabia
Saudi Arabia
United Arab
Emirates
Saudi Arabia
Study years Country
Author, year
Included studies
Table 2 Two ‘Study characteristics’
62 m
43 m
134 m
50 m
34 m
89 m
Results and conclusion
High prevalence of AAS use; inadequate awareness of
adverse effects; main source for AAS were online
methods; testosterone most commonly used AAS;
both oral and injectable forms used.
Recommended educational programs; tightening of
controls of sources of AAS.
Estimate AAS prevalence.
Cross-sectional survey.
High prevalence of AAS use; AAS use higher amongst
Determine awareness off AAS
Questionnaires (n = 154)
nationals, bodybuilders, weightlifters, and
adverse effects amongst users.
at gymnasiums.
commercial club users; 7% of non-users intended to
use AAS in the future; ROA not reported; main
source for AAS were fitness stores.
Recommended programs to increase awareness.
Estimate lifetime prevalence of Cross-sectional survey.
Prevalence of doping in Saudi Arabia is reportedly
doping.
Questionnaires (n = 1142)
4.3%. ROA and sourcing not reported; Improve
Address knowledge and attitudes
sport clubs, stadiums,
performance reason to use AAS; doping was
of doping.
and sports fields.
associated with low primary education.
Recommend advances in ‘doping’ screening.
Assess knowledge and practices Cross-sectional survey.
Limited awareness of AAS adverse effects. ROA not
of AAS users.
Questionnaires
reported; main source for AAS were gym coaches.
(n = 482) at
Recommended public education & health policy
gymnasiums.
reform.
Estimate AAS prevalence.
Cross-sectional survey.
High prevalence of AAS use; testosterone and
Examine AAS users’
Questionnaires (n = 150)
Deca-Durabolin most commonly used; both oral and
characteristics. Examine
at gymnasiums.
injectable forms used; pharmacies were main source
association between AAS
for AAS.
users and self-reported side
Recommended educational initiatives for youths.
effects.
Correlational study.
The study confirmed the applicability of the TPB to
explain AAS use of gym users. ROA not reported;
Methods
Estimate AAS prevalence.
Cross-sectional survey.
Determine awareness off AAS Questionnaires (n = 363)
adverse effects amongst users.
at fitness centres.
AAS users Aims
m/f
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Iran
Iran
2016
Not stated
2017
2011
Al Nozha and
Elshatarat
2017
Alsaeed and
Alabkal
2015.
Althobiti et al.
2018
Angoorani and
Halabchi
2015.
Asr et al. 2018. 2016
Kuwait
Arabia
Saudi
Study years Country
Included studies
Author, year
Table 2 (continued)
76 m
150 m
474 m
44 m
222 m
Results and conclusion
testosterone and Anadrol most used AAS.
Recommended using TPB to design prevention
programs for adolescents; and to help athletes reach
goals without AAS.
Assess user’s knowledge,
Cross-sectional survey.
Widespread misuse of PEAs in gyms in Saudi Arabia.
attitudes and beliefs about
Questionnaires (n = 316)
ROA not reported; testosterone most used AAS.
adverse effects of AAS.
at gymnasiums.
Recommended improving knowledge and awareness
Assess link between these factors
of AAS effects via health education; further research
and participants use of AAS.
to examine intervention effectiveness.
Assess gym user’s knowledge,
Cross-sectional study.
Significant differences between AAS users and
attitudes and AAS practice.
Questionnaires
non-users beliefs and attitudes to adverse effects of
(n = 194) at fitness
AAS. Peer effect is a factor in misuse of AAS. Both
centres.
oral and injectable ROA; main source for AAS is
gym trainers.
Assess gym user’s knowledge,
Cross-sectional survey.
All users had inadequate knowledge of AAS adverse
attitudes and AAS practice.
Questionnaires (n = 4860)
effects; both oral and injectable ROA; testosterone
at gymnasiums.
most commonly used AAS, then Dianabol; main
source for AAS is gym trainer.
Determine prevalence of AAS
Survey via interview
High prevalence of AAS use in Tehran; most used AAS
abuse.
using structured
nandrolone decanoate; ROA not reported;
questionnaires
psycho-socio- demographic factors associated with
(n = 906) at
AAS abuse.
gymnasiums.
Recommended recognising predisposing factors to
AAS use for use implementing education and
prevention programs.
Examine demographics and
Cross-sectional study.
Significant links between AAS use and attitudes, selfpsychosocial factors of AAS
Questionnaires
efficacy and AAS use of trainers and friends; ROA
use amongst bodybuilders
(n = 280) at
not reported; combined AAS most commonly used
gymnasiums.
followed by testosterone.
Methods
To explore gym users’ intentions Questionnaires (n = 253)
to us AAS based on the theory
at gymnasiums.
of planned behaviour (TPB).
AAS users Aims
m/f
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Not stated
Not stated.
2008
Not stated
Not stated
Bahri et al.
2017.
Boos et al.
2010
Bordbar et al.
2014
Fijan et al.
2018.
Habeeb et al.
2012.
Iraq
Iran
Iran
Iraq.
Saudi Arabia
Study years Country
Included studies
Author, year
Table 2 (continued)
95 m
96 m
11 m
14 m
144 m
Methods
Results and conclusion
Recommended educational interventions based on
social and individual factors.
Examine AAS prevalence.
Cross-sectional study.
High prevalence of AAS use; Deca-Durabolin and
Questionnaires
testosterone most commonly used AAS; both oral
(n = 465) at
and injecting practices reported.
gymnasiums.
Recommended increased awareness on adverse effects
of AAS use.
Establish AAS and dietary
Cross-sectional study.
High prevalence of AAS use; Deca-Durabolin and
supplements
Questionnaires (n = 1017).
testosterone most commonly used AAS; both oral
and injecting practices reported.
Recommended increased awareness on adverse effects
of AAS use.
Determine the frequency of and Descriptive, correlational Low prevalence of AAS use; AAS used or ROA not
attitudes to AAS use amongst
study. Questionnaires
reported; sourcing reportedly on military base.
athletic medical students.
(n = 271) university
Recommended greater awareness and more education
students.
re risks of AAS use and health-related effects.
Determine prevalence and
Cross-sectional study.
High AAS use amongst bodybuilders; AAS use
characteristics of AAS use.
Questionnaires
suggested by gym trainers; ROA and sourcing not
(n = 246) at
reported
gymnasiums.
Recommended further research e.g. longitudinal
studies.
Identify perceptions of substance Descriptive correlational Most participants began using dietary supplements
use of bodybuilders and
study. Questionnaires
only; influenced to us AAS by coach, friend,
athletes.
(n = 172) at
physician; both oral, injecting and a combination of
gymnasiums.
both ROA reported; Sourcing and type of AAS used
not reported.
Recommended further studies to determine
health-related adverse effects of AAS use.
AAS users Aims
m/f
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2015
Haerinejad
et al. 2016
Pakistan
Not stated
2015
2008–2009 Iran
Hussain et al.
2018
Jabari et al.
2016.
Jalilian et al.
2011
Saudi Arabia
Lebanon
Hitti et al. 2014 Not stated.
Iran
Study years Country
Included studies
Author, year
Table 2 (continued)
69 m
183 m
60 m
55 m
234 m
Evaluate AAS prevention
intervention effectiveness.
Determine prevalence of AAS
use and user knowledge of
AAS effects.
To understand levels of
anger/amongst AAS using
athletes.
Assess prevalence and
determinants AAS use.
Investigate prevalence and
characteristics of IPED us in
bodybuilders.
AAS users Aims
m/f
Results and conclusion
79.4% of athletes abused AAS; primary reason for use
was to increase muscle mass; sourcing was via
trainers, friends, gym partners, and pharmacies;
adverse effects most reported were sexual and
dermatologic; ROA was not reported.
Recommended evaluation AAS use in cycling and
wrestling.
Cross-sectional study.
Majority of AAS users aware of adverse effects;
Questionnaires
primary reason to use was to enhance body image;
(n = 523)
both oral and injecting ROAs; Deca most commonly
at fitness centres.
used AAS; sourcing was not reported.
Recommended monitoring AAS use in health clubs;
educational programs for high-risk groups.
Cross-sectional study.
AAS users showed higher anger levels than non-users;
Questionnaires
both oral and injecting ROA reported; testosterone
(n = 120).
most commonly used AAS; sourcing was via friends
and trainers.
Recommended further research into the effects of AAS
on mental health.
Cross-sectional Study.
High prevalence of AAS use; inadequate knowledge
Questionnaires (n = 600)
and awareness of harmful effects; ROA and sourcing
at gymnasiums.
not reported.
Recommended educating athletes on harmful effects;
legalising AAS to allow monitoring and control of
the substances.
Randomised
All participants used testosterone primarily; sourcing
pre-test–post-test series
and ROA was not reported; study found that
control group design
prevention intervention is effective in reducing AAS
panel study.
use.
Survey study.
Questionnaires
(n = 453) at
gymnasiums.
Methods
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Not stated
Not stated
2012–2013. Sudan
2010–2011
2007
Kargarfard
et al. 2015
Khullar et al.
2016.
Khidir and
Mahmoud
2018.
Melki et al.
2015.
Mohammad
2014.
Kuwait
Lebanon
Kuwait
Iran
Study years Country
Included studies
Author, year
Table 2 (continued)
202 m
518 m
3m
69 m, 1 f
924 m
Methods
Results and conclusion
Recommended further studies to include females.
Measure prevalence and attitudes Questionnaires (n = 1008) High prevalence of AAS use; Most commonly used
towards AAS use.
at Universities.
AAS was methane; ROA and sourcing not reported.
Recommended population specific AAS intervention
programs.
Determine lifetime prevalence of Questionnaires (n = 200) Lifetime prevalence of AAS use is high; sourcing not
AAS use.
at gymnasiums.
reported; both oral and injectable forms of AAS
used.
Recommended health policy and institutional reforms
help diminish rising AAS use; treat AAS as illicit
substances and as a public health concern; public
health campaigns; and increased education re harms.
Examine athlete’s knowledge of Cross-sectional study.
Low prevalence of AAS use; most were aware of
doping in sport.
Questionnaires (n = 60)
banned substances in sport; majority unaware of
amongst athletes.
doping tests; ROA, sourcing and most used AAS not
reported.
Recommended education at earlier stages in school;
education for coaches and trainers.
Examine links between AAS use Cross-sectional survey.
Study describes AAS uses as a significant public health
and sociocultural factors such
Questionnaires
issue; majority had awareness of adverse effects;
as media and male
(n = 523) at fitness
AAS users consume extreme amounts of media and TV
muscularity.
centres.
related to muscularity; ROA and sourcing of AAS
not reported.
Determine AAS use prevalence Questionnaires (n = 1708) Inadequate knowledge of adverse effects; lack of public
and user attitudes of their use.
at sports clubs.
awareness of effects; 59% believed benefits of AAS
use outweighed risks; encouraged to use AAS by
coaches and friends; oral ROA only reported;
sourcing not reported. Recommended national
campaign to advise short- and long-term adverse
AAS users Aims
m/f
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2013
2011
2012
2015
Not stated
Nakhaee et al.
2013.
Razavi et al.
2014.
Rezaei 2017
Saeidinejat
et al. 2017.
Sepehri et al.
2009
Iran
Iran
Iran
Iran
Iran
Study years Country
Included studies
Author, year
Table 2 (continued)
164 m
311 m
87 m, 5 f
72 m
73 m
Methods
Questionnaires (n = 214)
at gymnasiums
Determine types of AAS used
and frequency of AAS use in
bodybuilders.
Cross-sectional survey.
Questionnaires (n = 202)
at gymnasiums.
Evaluate prevalence of AAS use. Descriptive-analytical
Cross-sectional study.
Questionnaires
(n = 920) at gymnasiums.
Determine prevalence of AAS
use.
Examine prevalence of drug use, Cross-sectional study.
particularly anabolic steroids Questionnaires (n = 298)
amongst bodybuilders.
at gymnasiums.
Determine prevalence and
Cross-sectional study.
patterns of AAS use by
Questionnaires
bodybuilders.
(n = 250) at
gymnasiums
AAS users Aims
m/f
effects; prevention interventions with youths; further
research on socioeconomic and behavioural determinants of AAS use.
High prevalence of drug use including AAS amongst
bodybuilders; ROA and sourcing were not reported;
AAS use recommended by peers and coaches.
High frequency of AAS use; AAS use suggested by
peers and coaches; testosterone most commonly
used; both oral and injecting ROA reported; sourcing
was not reported.
Recommended further research into underlying reasons
to use; implement effective prevention measures
amongst youths.
High prevalence of AAS use; many had little to no
awareness of adverse effects; both oral and injecting
ROAs reported; sourcing was not reported;
testosterone most commonly used AAS.
Recommended further studies and interventions for
youths and athletes.
Low awareness of knowledge of adverse effects; most
commonly used AAS dianabol, testosterone and
oxynandrolone; ROA and sourcing not reported.
Recommended education for adolescents and youths
at high schools, universities and sports clubs;
assessing coaches also regarding AAS use; enforcing
law.
Most commonly used AAS oxymetholone; sourcing
primarily ‘black market’, and pharmacy; Reasons to
use AAS reportedly due to advice from friends and
Results and conclusion
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Jordan
Not stated.
Not stated.
2012–2013 Jordan
Tahtamouni
et al. 2008.
Uddin et al.
2019
Wazaify et al.
2014
Pakistan
Iran
Study years Country
Included studies
Sobhanian et al. 2012
2013
Author, year
Table 2 (continued)
31 n/s
502 m
61 m
154 m
Investigate abuse of OTC and
prescription products in
gymnasiums.
Investigate prevalence,
knowledge, attitudes, and
practices of AAS use.
Measure extent of AAS abuse
amongst students and
bodybuilders.
Evaluate prevalence of AAS in
bodybuilders.
AAS users Aims
m/f
Results and conclusion
coaches; ROA not reported. Recommended
educational programs for athletes regarding the
adverse effects of AAS use; healthcare systems
should also provide information to bodybuilders and
athletes.
Cross-sectional study.
High prevalence of AAS use in study (51.5%);
Questionnaires (n = 299)
testosterone most commonly used; both oral and
at gymnasiums.
injecting ROA reported; sourcing primarily from
coaches and supplement suppliers.
Questionnaire (n = 657) of Financial status was found to be main risk factor for
university students and
AAS abuse; one third began using before aged
bodybuilders.
15 years;
Deca-Durabolin most commonly used AAS; friends
and trainers are primary sources of AAS; ROA not
reported. Recommended educational organisations
conduct further surveys to measure AAS prevalence;
new interventions for users.
Cross-sectional study.
More than half participants reported AAS use; friends
Questionnaires (n = 841)
and online were main sources; ROA and AAS most
used not reported; aggression, mood swings, heart
problems and infertility reported.
Recommended sport and health policy-makers highlight AAS adverse effects; regulation of
markets/sources of AAS.
Cross-sectional survey.
More than a quarter had never heard of AAS; injecting
Questionnaires (n = 353)
primary ROA; testosterone most commonly used
AAS; sourcing was not reported. Adverse effects
reported by AAS users included tachycardia,
palpitations, hypertension, priapism, testicular
Methods
International Journal of Mental Health and Addiction (2021) 19:1162–1189
1173
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Conference
Proceedings
Alsamani
et al. 2017
Not stated.
Not stated.
Zafar et al.
2018
Bahrain
Pakistan
Study years Country
Included studies
Author, year
Table 2 (continued)
16 m
98 m
Investigate prevalence,
knowledge, attitudes and
practices of AAS.
Evaluate AAS use in gyms.
AAS users Aims
m/f
atrophy, renal, and psychological problems.
Recommended enforcing of WADA regulations by
MOH inspectors at pharmacies; raise more
awareness amongst younger people and coaches.
Further qualitative research.
46% reported AAS current/former use; most common
ROA was injecting; sourcing and most commonly
used AAS not reported.
Results and conclusion
Questionnaire (n = 103) at Awareness of adverse effects was high despite
gymnasiums.
continued use; ROA and sourcing were not reported.
Survey questionnaires
(n = 630)
Methods
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
1175
Profile of AAS Users in the Middle East
The quantitative studies from Iran (n = 14), Saudi Arabia (n = 7), Kuwait (n = 4), Lebanon (n = 2), United Arab Emirates (n = 1), Iraq (n = 2), Jordan (n = 2), Pakistan (n = 3),
Sudan (n = 1), and conference proceedings from Bahrain (n = 1) generated a total of 5425
current and former AAS users. A total of 5371 of these were male and only 6 were
female. Three studies did not detail whether the AAS users were male or female (Boos
et al. 2010; Khidir and Mahmoud 2018; Wazaify et al. 2014) although female participants were included in their studies. The age range of AAS users ranged from 14 to
60 years old (Al-Falasi et al. 2008; Al Ghobain et al. 2016; Alharbi et al. 2019;
Allahverdipour et al. 2012; Al Nozh & Elshatarat, 2017; Alsaeed and Alabkal 2015;
Althobiti et al. 2018; Angoorani and Halabchi 2015; Asr et al. 2018; Bahri et al. 2017;
Boos et al. 2010; Jabari et al. 2016; Khullar et al. 2016; Bordbar et al. 2014; Fijan et al.
2018; Habeeb et al. 2012; Haerinejad et al. 2016; Hitti et al. 2014; Hussain et al. 2018;
Jalilian et al. 2011; Kargarfard et al. 2015; Khidir and Mahmoud 2018; Melki et al. 2015;
Mohammad 2014; Razavi et al. 2014; Tahtamouni et al. 2008; Uddin et al. 2019;
Wazaify et al. 2014; Zafar et al. 2018). Seven studies did not clearly state age or age
range (Allafi et al. 2019; Alsamani et al. 2017; Nakhaee et al. 2013; Rezaie, 2017;
Saeidinejat et al. 2017; Sepehri et al. 2009; Sobhanian et al. 2013). Participants were
from Iran, Saudi Arabia, United Arab Emirates, Kuwait, Lebanon, Jordan, Iraq, Bahrain,
Pakistan, and Sudan, with no notable differences in age ranges between countries. Those
aged 18–34 years reported using AAS to a greater extent than other age groups (14–17
and 35–59 years). Not all studies reported on background characteristics such as marital
status, employment status, and education. Studies that did report on demographics are
presented in Table 3.
Gymnasium Practice in the Eastern Mediterranean Region
Gymnasium practice was not reported by twenty-one peer reviewed journal papers (Al
Ghobain et al. 2016; Allafi et al. 2019; Al Nozha and Elshatarat 2017; Alsaeed and Alabkal
2015; Alsamani et al. 2017; Althobiti et al. 2018; Asr et al. 2018; Boos et al. 2010, 2011;
Bordbar et al. 2014; Haerinejad et al. 2016; Hitti et al. 2014; Jabari et al. 2016; Kargarfard
et al. 2015; Khullar et al. 2016; Khidir and Mahmoud 2018; Melki et al. 2015; Mohammad
2014; Nakhaee et al. 2013; Saeidinejat et al. 2017; Sobhanian et al. 2013; Tahtamouni et al.
2008). The types of gyms and fitness clubs where AAS were used included gymnastics clubs
(Saudi Arabia), commercial gyms and social clubs (Saudi Arabia, United Arab Emirates, Iraq,
Iran, Pakistan), hotel gyms (United Arab Emirates), private clubs (Saudi Arabia), bodybuilding
clubs (Iran, Saudi Arabia, Kuwait), sports centres (Pakistan), martial arts clubs (Saudi Arabia),
rec centres (Pakistan), and athletic clubs (Iran) (Al Bishi and Afify 2017; Al-Falasi et al. 2008;
Alharbi et al. 2019; Alsamani et al. 2017; Angoorani and Halabchi 2015; Bahri et al. 2017;
Fijan et al. 2018; Habeeb et al. 2012; Haerinejad et al. 2016; Hussain et al. 2018; Jalilian et al.
2011; Kargarfard et al. 2015; Mohammad 2014; Nakhaee et al. 2013; Razavi et al. 2014;
Rezaei 2017; Sepehri et al. 2009; Sobhanian et al. 2013; Tahtamouni et al. 2008; Uddin et al.
2019; Zafar et al. 2018). The remaining fifteen papers did not state the type of settings they
recruited participants from.
Users reported using gymnasia for less than 6 months (n = 31), more than 6 months (n =
165), more than 2 years (n = 107), more than 4 years (n = 54) and one paper reported 11 months
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Table 3 Background characteristics
Characteristics
Marital status
Married
Single
Divorced
Level of education
Basic education
Higher education
Secondary school
Primary School
Technical
Employment status
Employed
Unemployed
Student
Country
n
%
Saudi Arabia
UAE
Iran
Lebanon
Kuwait
Saudi Arabia
UAE
Iran
Lebanon
Kuwait
Saudi Arabia
Lebanon
235
16
164
67
12
322
17
608
499
190
14
6
41.16
48.48
21.24
11.71
5.94
56.39
51.52
78.76
87.24
94.06
2.45
1.05
Saudi Arabia
Kuwait
Saudi Arabia
Kuwait
UAE
Iran
Lebanon
Bahrain
Saudi Arabia
Kuwait
UAE
Iran
Lebanon
Saudi Arabia
Kuwait
UAE
Iran
Lebanon
Bahrain
Lebanon
46
12
492
123
7
606
438
70
204
64
20
42
56
11
40
7
333
30
33
45
6.11
5.02
65.34
51.46
20.59
61.77
76.98
67.96
27.09
26.78
58.82
4.28
9.84
1.46
16.74
20.59
33.94
5.27
32.04
7.91
Saudi Arabia
UAE
Iran
Lebanon
Iraq
Jordan
Saudi Arabia
UAE
Iran
Lebanon
Saudi Arabia
UAE
Lebanon
427
25
9
376
14
2
25
1
51
196
236
8
9
62.06
73.53
15.00
64.72
1.4
100.00
3.63
2.94
85.00
33.73
34.30
23.53
1.55
to 10 years (Jalilian et al. 2011). Users spent between two and five days (n = 75), more than
three days (n = 18), and more than five days (n = 72) per week at their chosen gymnasium.
Reasons for attending a gymnasium included bodybuilding, muscle building, professional
training and daily gym practice (Al Bishi and Afify 2017; Al-Falasi et al. 2008; Alharbi et al.
2019; Althobiti et al. 2018).
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
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AAS Regimes of Use in the Eastern Mediterranean Region
Sourcing of AAS was not investigated by more than half of the included studies (Al
Ghobain et al. 2016; Allahverdipour et al. 2012; Al Nozha and Elshatarat 2017; Alsamani
et al. 2017; Angoorani and Halabchi 2015;Asr et al. 2018; Bahri et al. 2017; Bordbar et al.
2014; Fijan et al. 2018; Jabari et al. 2016; Jalilian et al. 2011: Karfargard et al., 2015;
Khullar et al. 2016; Khidir and Mahmoud 2018; Melki et al. 2015; Mohammad 2014;
Razavi et al. 2014; Rezaie, 2017; Saeidinejat et al. 2017; Zafar et al. 2018). However,
research conducted in Saudi Arabia, United Arab Emirates, Kuwait, Iran, Iraq, Lebanon,
Pakistan, and Jordan did report sourcing. Purchasing from friends, gym trainers, and
coaches were the primary sourcing routes in these countries. Other sourcing routes
included sourcing via gym members, training partners, the black market, online purchasing, pharmacists, physicians, veterinary surgeons, fitness stores, and purchasing abroad
and bringing home. One military based study reported sourcing on site (Boos et al. 2010),
i.e. the Contingency Operating Base and the PX retail store on base.
A range of AAS and other IPEDs were reported as being used. Sixteen studies (Al
Bishi and Afify 2017; Allafi et al. 2019; Allahverdipour et al. 2012; Al Nozha and
Elshatarat 2017; Alsaeed and Alabkal 2015; Althobiti et al. 2018; Angoorani and
Halabchi 2015; Asr et al. 2018; Bahri et al. 2017; Hitti et al. 2014; Hussain et al.
2018; Jalilian et al. 2011; Kargarfard et al. 2015; Mohammad 2014; Razavi et al. 2014;
Wazaify et al. 2014) reported on the types of AAS and associated drugs being used. The
most commonly reported injectable were testosterone and nandrolone decanoate, and the
most common oral AAS used were methandrostenolone and stanozolol, with the use of
growth hormone reported in only four studies. Routes of administration (ROA) were
reported in less than half of the studies (Al Bishi and Afify 2017; Allafi et al. 2019;
Alsaeed and Alabkal 2015; Bahri et al. 2017; Habeeb et al. 2012; Hitti et al. 2014;
Hussain et al. 2018; Khullar et al. 2016; Razavi et al. 2014; Wazaify et al. 2014; Zafar
et al. 2018) highlighting injecting as the predominant choice of ROA amongst users.
Sobhanian et al. (2013) did not elaborate on the predominant route but reported both oral
and injecting routes of administration. Their research also interestingly gave detailed
information regarding the person administering the injection of AAS to the user (other
than self) which included coach (n = 9); coach, teammate, or nurse (n = 1); coach or
friend (n = 1); coach or nurse (n = 1); coach or physician (n = 1); physician (n = 4);
teammate (n = 6); teammate or nurse (n = 1); friend (n = 4); family member (n = 1);
another athlete (n = 8).
Duration of AAS use was only reported in a small number of articles (Al Bishi and Afify
2017; Alsamani et al. 2017; Asr et al. 2018; Bahri et al. 2017; Sobhanian et al. 2013) and
ranged from less than 1 month to more than 5 years. One study in Saudi Arabia reported that
69.7% of AAS user participants simply had no knowledge of their duration of AAS use (Jabari
et al. 2016). Twenty-five papers did not report duration of AAS use.
Thirteen studies in United Arab Emirates, Saudi Arabia, Kuwait, Sudan and Iran did
not report on the reasons for AAS use (Al-Falasi et al. 2008; Alharbi et al. 2019; Allafi
et al. 2019; Al Nozha and Elshatarat 2017; Alsaeed and Alabkal 2015; Angoorani and
Halabchi 2015; Althobiti et al. 2018; Bahri et al. 2017; Bordbar et al. 2014; Jalilian et al.
2011; Kargarfard et al. 2015; Khidir and Mahmoud 2018; Razavi et al. 2014). Reasons
for use of AAS were largely stated as being to improve image, appearance, and overall
physique; to increase muscle mass and improve strength and power; achieve
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‘attractiveness’; to improve athletic performance; to increase chances of winning bodybuilding competitions; to increase self-confidence and social recognition; and due to
advice or recommendation from friends, trainers, and physicians. Other less predominant
reasons for use were to increase sex drive, weight gain, fat burning, aid recovery,
unspecified medical reasons, and to enhance energy.
The adverse effects of AAS use were not investigated by all studies, with twenty-four
papers not reporting on these effects. Self-reported effects by the remaining studies in Kuwait,
Bahrain, Saudi Arabia, Iran, and Jordan were aggression, depression, sexual problems,
increased appetite, acne, hair loss, gynecomastia, mood changes, fluid retention, headaches,
increased hair growth, cardiovascular problems, psychiatric issues, and hepatic and renal
damage (Allafi et al. 2019; Alsamani et al. 2017; Althobiti et al. 2018; Bahri et al. 2017;
Haerinejad et al. 2016; Hussain et al. 2018; Razavi et al. 2014; Tahtamouni et al. 2008; Uddin
et al. 2019; Wazaify et al. 2014). The study by Habeeb et al. (2012) stated that most AAS users
reported the use of only dietary supplements initially, but on recommendation of others,
initiated the use of AAS to improve performance.
Knowledge and Understanding of the AAS Concept and Adverse Effects
Studies included in this review reported on user’s knowledge of the AAS ‘concept’ (i.e.
their understanding of and expected outcomes of AAS use). Thirteen studies in Kuwait,
Iran, Iraq, and Jordan did not examine user’s knowledge and understanding of either AAS
concept or adverse effects (Allafi et al. 2019; Allahverdipour et al. 2012; Angoorani and
Halabchi 2015; Asr et al. 2018; Boos et al. 2010; Fijan et al. 2018; Habeeb et al. 2012;
Hussain et al. 2018; Jalilian et al. 2011; Khullar et al. 2016; Sepehri et al. 2009; Sobhanian
et al. 2013; Tahtamouni et al. 2008). It was noted that most participants in these Eastern
Mediterranean countries were aware of the anabolic effects of AAS such as increased
muscle mass, bodybuilding effects, increased in body weight, and increased muscle
strength (Al Bishi and Afify 2017; Al-Falasi et al. 2008; Mohammad 2014). In relation
to adverse effects, several papers in Saudi Arabia, United Arab Emirates, Kuwait, and Iran
reported an inadequate level of self-reported knowledge overall amongst participants (Al
Bishi and Afify 2017; Al-Falasi et al. 2008; Alharbi et al. 2019; Alsaeed and Alabkal
2015; Althobiti et al. 2018; Bahri et al. 2017; Jabari et al. 2016; Khidir and Mahmoud
2018; Mohammad 2014; Rezaei 2017; Uddin et al. 2019; Wazaify et al. 2014; Zafar et al.
2018). Less than half of the participants of the study by Al-Falasi et al. (2008) in the
United Arab Emirates had any knowledge of either physical or psychological adverse
effects A high number of participants of the study by Alharbi et al. (2019) in Saudi Arabia
answered ‘I don’t know’ when also asked about their awareness of these adverse effects.
Haerinejad et al. (2016) reported that the majority of participants had no knowledge of
adverse effects prior to use. One study reported that although users (n = 16) had knowledge
of adverse effects, they continued to use AAS (Kargarfard et al. 2015).
One study reported that overall, it was believed that the benefits of ASS on muscle growth
outweighed its adverse harmful effects (Alsaeed and Alabkal 2015). Bordbar et al.’s (2014)
study in Iran found that a small number of participants believed that athletes should be allowed
to use AAS for athletic performance. Jabari et al. (2016) in Saudi Arabia found that 77% of
participants who self-declared knowledge of the adverse effects of AAS would still recommend them to friends. Hitti et al. (2014) noted that users of AAS were more likely to consume
alcohol daily than non-AAS users.
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
1179
Discussion
We present here the first known attempt to map and describe extant literature on the use of
AAS in the Eastern Mediterranean, an emergent phenomenon in the region, and one which we
speculate is at early stages of diffusion. Countries where publications were located include
Saudi Arabia, United Arab Emirates, Kuwait, Iran, Iraq, Lebanon, Jordan, Bahrain, Afghanistan, Pakistan, and Sudan. Whilst we adhere to the robust Arksey and O Malley protocol for
scoping review, we recognise that this review is compromised due to the following limitations.
Firstly, only empirical studies were included in the search and investigative journalist reports
were not included thus limiting the scope. Secondly, some studies were undertaken in the same
country, whereby we do not know if individuals participated in more than one survey, creating
a potential overlap, and over estimation of numbers of AAS users. Thirdly, it is unclear as to
whether participants were citizens of these countries or whether they were foreigners from
other more Westernised cultures. Western influences potentially impact on a country’s body
ideals, perceptions of masculinity, popularity of exercise and experimentation, and use of
enhancement drugs. Religion or faith of the participants was not asked; therefore, we cannot
assume that participants are of the Islamic faith. Lastly, some studies did not provide extensive
detail on all countries participating in their surveys. Hence, this scoping review should be
viewed with caution as it cannot provide an accurate contemporary interpretation of AAS use
in the Eastern Mediterranean region. It does however give us insight into the phenomenon at
early stages of diffusion with regard to rationales for use, knowledge around use, regimes,
locations of use, and sourcing routes.
The use of AAS for performance and image enhancement is a growing concern in these
countries; however, knowledge, understanding, and awareness of health harms related to AAS
appear to be varied and somewhat limited. Most studies in this review reported AAS users as
single and in fulltime employment, highlighting high rates of employment, similar to studies in
the UK (Baker et al. 2008; Begley et al. 2017; Greenway and Price 2018), Australia (Jacka
et al. 2017), and the USA (Pope et al. 2014a, 2014b). Educational status of AAS current and
former users in the Middle East was highest in the ‘higher education’ range which corroborates
research in Australia (Cohen et al. 2007) and the USA (Westerman et al. 2016). Duration of the
use of AAS was underreported overall; the maximum length of use reported was 5 years,
indicating that the use of AAS amongst some gym populations in the Middle East is clearly
established. However, when compared with studies in the UK (Baker et al. 2008; Begley et al.
2017; Greenway and Price 2018), Australia (Jacka et al. 2017), and the USA (Pope et al.
2014a, 2014b), it is evident that this phenomenon is at an early stage of diffusion. This has
implications for design of culturally appropriate health-related interventions underpinned by
harm reduction and cessation supports in the Eastern Mediterranean. We underscore implications for normalisation of this form of enhancement drug use amongst athletes and gym goers
(Mulrooney et al. 2019), with this review providing a key starting point for interventions prior
to normalisation of use. There is growing evidence of the possibility of deleterious effects of
long-term AAS use on the health of a user’s brain (Bjornebekk et al. 2017) and cognitive
defects in long-term high dose users (Kanayama et al. 2013).
Research has indicated that factors contributing to decisions to use AAS include beliefs and
personal traits (Bates et al. 2018). Building muscle and enhancing physique and training
aspects were the primary reasons for gymnasium attendance amongst individuals reporting
AAS use in the Eastern Mediterranean. Some less predominant reasons for AAS use centred
on desire to increase sex drive, weight gain, fat burning, help improve an injury, medical
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
reasons, and for more energy. Literature shows that AAS are used for the improvement of
physique, increased muscle mass, strength enhancement, and athletic performance enhancement (Begley et al. 2017; Brennan et al. 2016; Ip et al. 2011; Ip et al. 2015; Zahnow et al.
2018). Masculinity is a social construct, as is femininity, and is associated with specific values
and cultural contexts (Darwish, 2009). The review suggests that AAS use is overwhelmingly
male indicating the presence of this masculine culture, with only a small number of studies
reporting female use. This largely reflects the evidence from established literature outside the
Eastern Mediterranean, where female use exists at much lower levels than male use and is
characterised by stigma and secrecy (Chandler and McVeigh 2014; Ip et al. 2010; Sagoe et al.
2014a, 2014b) but to a lesser extent than males (Brennan et al. 2016).
We recognise that gender and religiosity are symbiotic in their relationship in that religious
symbolism facilitates the male ego (Aslam 2012). In other countries, men have a higher
prevalence of AAS use than females for example in the USA (Kashkin and Kleber 1989;
Tokish et al. 2004; Yesalis 2001), UK (Begley et al. 2017), Poland (Rachoń et al. 2006), and
Sweden (Lindqvist et al. 2013), and as such, these findings reflect gender differences in use
found in other countries. Islamic faith however prohibits intoxication from alcohol and the use
of substances or behaviours that induce addiction such as illicit drugs or gambling (Crabtree
et al. 2017; Salaymeh 2015). As mentioned earlier, we do not have participant profile in terms
of their citizenship or religiosity. Van Hout and Kean (2015) reported that male Muslim users
of AAS and other IPEDs in the UK felt these substances led them to be in control of and
promoted their perceptions of their physical and spiritual health, and were not harmful, thus
circumventing religious parameters. In addition, we recognise that use of AAS in Islamic faith
is discouraged and the legality of AAS is unclear in some Eastern Mediterranean countries
where regulatory controls are complex and varied. Of interest is that one study, namely,
Angoorani and Halabchi (2015) observed a 25% prevalence of AAS use in their all-female
study. This is perhaps indicative of the lower proportion of females attending mainstream gyms
(and commonly not attending male gyms) in the included studies (Donnelly et al. 2018).
Users of AAS had some knowledge of the anabolic effects of AAS and the overall AAS
‘concept’ such as increased muscle mass, bodybuilding effects, and increased power and muscle
strength. There was however a concerning and inadequate level of knowledge around adverse
effects and health problems (Al Bishi and Afify 2017; Al-Falasi et al. 2008; Alharbi et al. 2019;
Alsaeed and Alabkal 2015; Bahri et al. 2017; Jabari et al. 2016; Rezaei 2017). Aggression is a
reported adverse psychological effect of AAS use (Bahrke et al. 1996; Bahrke et al. 1990; Pope et al.
2000). Lack of knowledge on such adverse effects is not uncommon and has also been reported in
studies in Australia (Yager and O’Dea 2014), Sweden (Nilsson et al. 2005), and the USA (Hoffman
et al. 2008). Worldwide, enhanced levels of awareness and knowledge are warranted to support
choices to use safely (Nilsson et al. 2005). Of those that included ROA in their surveys, injecting was
reported as the predominant route of administration. This may indicate presence of only a small
cohort of oral AAS users (similar to recent research by van de Ven et al. (2019)). Blood-borne virus
(BBV) transmission associated with any form of injecting drug use is a major public health concern
(Hearne et al. 2016; Hope et al. 2013; Van Hout 2014). Of note was that questions relating to sharing
of injecting equipment or knowledge and awareness of blood-borne virus (BBV) transmission were
not asked in the included records. Some records did however refer to the injection of the user by gym
trainers; however, harms that may result from this practice were also not investigated further. Of note
is the limited reference to support from healthcare professionals to this community. Clearly, there is a
role for health professionals in relation to prevention and harm reduction with the potential for
pharmacists to take the leading role.
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International Journal of Mental Health and Addiction (2021) 19:1162–1189
1181
Lastly, sourcing of AAS was reported in a limited number of studies and highlighted how
AAS users are highly influenced by availability in gym settings and by coaches and trainers.
Some reported being recommended to use AAS by them (Razavi et al. 2014; Fijan et al. 2018)
and also sourcing their AAS from them, which supports similar research elsewhere (Fincoeur
et al. 2015; Maycock and Howat 2007; Santos and Coomber 2017), given that AAS and
associated drugs are illicitly manufactured and sourced (Begley et al. 2017) via routes such as
online marketplaces and online private sellers (Brennan et al. 2016), and with low resource
countries increasingly involved in manufacture and as transit routes(Evans-Brown et al. 2009).
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and
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exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy
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